The city branded a cancer capital is fighting back with a two pronged action plan
Liverpool has been called the lung cancer capital of the world. Rates here are two and a half times higher than the national average. But cigarettes are not the only things that entice the people of Mersey and Cheshire to gamble with their health.
An eye catching poster offers a special sunbed bargain: "60 minutes - for only£15" trumpets the tanning advertisement. A recent survey in eight Merseyside schools found that more than half of 14-15 year olds use sunbeds. Research shows that using sunbeds under the age of 35 can double the risk of malignant melanoma - the most dangerous kind of skin cancer.
In a café around the corner from the Beatles Museum, a young waitress sports a sweatshirt with the slogan: All You Need Is Grub. She is perhaps four stone overweight. But it is unlikely that she associates weight with cancer risk.
None of these scenarios is found exclusively in Liverpool. But it is an unpalatable truth that the people of Merseyside and Cheshire have some of the worst cancer mortality rates in the country.
There are also daunting inequalities here compared with other parts of England.
So when policy makers in the local public health and cancer networks met to discuss these problems, they decided they had to work together to tackle them.
The result is a two year strategy devised by public health professionals working with clinicians, nurses, patients and carers.
The aim is twofold. First: cut cancer deaths through earlier diagnosis and reduce the number of people who develop cancer through prevention messages. Second: reduce health inequalities through improved detection and prevention of cancer. And the strategy is a shining example of good practice, according to Kathy Elliott, public health consultant for the national cancer action team.
"This action plan shows what can be done. They have produced a toolkit which gives plenty of suggestions and advice for other cancer networks," says Ms Elliott.
Former GP Daniel Seddon, consultant in public health medicine at Halton and St Helen's primary care trust, wrote the initial proposal.
"We had discussions with the Cancer Registry and the North West public health observatory and commissioned university research so we could pull together an evidence base on inequalities," says Dr Seddon.
"We looked at cancer incidence and survival in primary care trusts and groups and evaluated inequalities among those with mental health problems, physical disabilities and in ethnic minorities. Then we organised a workshop for stakeholders and presented the results."
This first workshop invited public health researchers, epidemiologists, cancer patients, carers and some clinicians to participate. After a long hard day of discussion - and some argument - it was decided that the Merseyside and Cheshire strategy should focus on six cancers which highlighted inequalities in the North West through high incidence or mortality or low uptake of screening.
These were cancers of the bladder, breast, cervix, bowel and lung, and malignant melanoma.
Focus on early detection
Dr Seddon admitted it was a challenge to pick just six cancers and that prostate cancer groups were disappointed they had not been included.
"It was difficult to restrict the focus to six but our priority must be to concentrate on early detection and prevention where possible," he says. "Embarrassment, a lack of knowledge and fear of bad news keeps people out of the doctor's surgery. There is a common assumption that cancer presents itself very dramatically but often the process is gradual, with people dismissing what are actually serious symptoms as something that will go away."
These concerns were highlighted last November at the launch of the national awareness and early diagnosis initiative led by Cancer Research UK. Sara Hiom, the charity's health information director, says the initiative is working to promote symptom awareness "and we hope the Merseyside strategy will feed into other cancer networks".
The next step in developing the strategy was a second workshop - attended by more clinicians - where it was agreed to concentrate on five action plans.
Top of the list was cancer staging. There was concern that when cancers were registered at the North West cancer intelligence network fewer than half recorded the stage of the cancer at diagnosis. It was agreed that urging clinicians to record this information was a priority.
Other plans included improving cancer screening performance to reduce inequalities, focusing on young people through the healthy schools initiative and ensuring health messages are clear and easy to understand.
It was also decided to use social marketing to target individual groups, such as those with mental health problems, or elderly people, to find out the best ways to communicate specific health messages to individual communities.
Paul Mackenzie, a former nurse in palliative care and now inequalities manager at Merseyside and Cheshire cancer network, explained how social marketing had been used locally to engage different groups about bowel cancer screening.
"Volunteers from the healthy communities collaborative - dressed in boxer shorts with a picture of a plastic bottom on the back - were sent to walk around in Boots the chemist. We hoped that shoppers would stop to chat and then they would get information about bowel screening.
"This worked really well in Liverpool - which traditionally has a great sense of humour. Lots of shoppers really engaged with the idea."
Flexible approach
But the same stunt fell flat in nearby St Helen's ,where nobody wanted to get involved, "so we printed a leaflet like a bookmark and that worked better."
Mr Mackenzie emphasises that a successful strategy must have "buy in" from as many organisations as possible. "We recognised we couldn't do everything ourselves and networks need to work together."
Overall the strategy has made a real difference to uptake of bowel screening through media campaigns involving patients, and by producing information in a range of languages. Uptake in Cheshire and Merseyside has been nearly 60 per cent, rising to 70 per cent in some areas - well above the national average.
Also supporting the strategy are the Sexual Health Network and Champs - Cheshire and Merseyside Public Health Network, whose communications manager Tony Ellis initially felt overwhelmed at the prospect of tackling such a huge cancer problem.
"But then I remembered Liverpool was the first city in England to have a medical officer for health, when William Henry Duncan was appointed in the 1840s to tackle the cholera epidemic. We have a good track record in Liverpool."
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